Inquest into the death of Carley METCALFE

Contributing factors

• acute psychotic episode with untreated schizophrenia
• cessation of antipsychotic medication (olanzapine) and methadone
• miscommunication between emergency department and mental health teams
• inaccurate diagnosis of acute intoxication rather than psychosis
• inadequate discharge planning and lack of family notification
• absence of formal documented risk assessment by police
• delayed and inadequate missing person investigation
• failure to obtain CCTV footage in timely manner
• lack of access to prior psychiatric diagnosis from forensic assessment

Coroner's recommendations

1. MPR to amend definition of missing person in MP SOPs to clarify that no particular form of words need be used—if communicated that person cannot be located and concerns for safety/welfare exist, that person is missing
2. MPR to require police identify, obtain and safely store last known CCTV footage within first 48 hours of missing person investigation and make clear CCTV is valuable even if forensic significance not immediately apparent
3. MPR to include identifying and obtaining potentially relevant CCTV footage in mandatory investigation timeframes for Officer in Charge, ideally within 48 hours
4. NNSW LHD ensure summary document page on HealtheNet includes past admissions, psychiatric diagnoses, mental health-related incidents (violence, self-harm, suicide attempts), and other relevant information for assessing clinicians
5. NNSW LHD expand scanning project to cover all hospitals and medical centres so paper records for mental health patients available in Electronic Medical Records System
6. NNSW LHD formalise written procedure requiring inpatient mental health units and community mental health services to obtain medical records and assessment reports from Justice Health and other sources where patient psychiatrically assessed in custody and records clinically relevant; and press for records to be scanned or electronically available to clinicians
7. NNSW LHD introduce instant saliva-based testing for detection of illicit drug use by mental health clinicians in emergency departments and elsewhere as required
8. NNSW LHD assess and determine need for Psychiatric Emergency Care Centre at Lismore Base Hospital